BUFFALO, N.Y. — If you’re about to undergo brain
surgery, you likely aren’t thinking about what your surgeon
is wearing on his or her head.

But headwear for surgeons and the teams that care for surgical
patients is the subject of a serious, public debate between two key
organizations: the Association of periOperative Registered Nurses
(AORN) and the American College of Surgeons (ACS), both of which
are dedicated to improving the care of surgical patients.

Surgeons from the Jacobs School of Medicine and Biomedical
Sciences at the University at Buffalo and Kaleida Health have
entered the national discussion. They did so with a scientific study
published in Neurosurgery last spring, the largest published study
on the effect of head gear upon rates of surgical site infections,
and this week with an invited commentary
published in the October Bulletin of the ACS.

Kevin Gibbons, MD, senior and lead author on both publications,
is senior associate dean for clinical affairs at UB, chief of
neurosurgery at Kaleida Health, physician director of surgical
services at the Buffalo General Medical Center and executive
director of UBMD Physicians’ Group. He described the
controversy this way:

“AORN’s position is that any head covering that
doesn’t cover all hair, as well as the surgeon’s ears
should be banned from the operating room. The rationale was that
since hair harbors bacteria, leaving some of a surgeon’s hair
and ears uncovered — as traditional surgical skullcaps do
— could put patients at higher risk of surgical site
infections. The leadership of AORN argues there is no harm in
eliminating the cap and there may be benefit in terms of reduced
surgical site infections. The result of this interpretation
resulted in hospitals around the country being cited by outside
reviewers for poor infection control practice if anyone in the OR
was seen wearing a surgical cap.”

Hospitals, he said, responded by outlawing caps to comply with
the mandate. That’s what happened in February 2015 at Buffalo
General, Kaleida Health’s biggest hospital and the largest
training site for the Jacobs School of Medicine and Biomedical
Sciences.

Infection question

“This ban on the cap provided us with an opportunity to
examine infection rates in so-called ‘clean’ cases
before and after the ban,” said Gibbons. “The study
demonstrated no change in infection rates in almost 16,000 surgical
cases.”

At the time the study was published in spring 2017, it was the
journal’s most widely read paper, according to the
journal’s website. But despite the findings, the debate has
continued.

“There were accusations that surgeons just wanted to hold
onto this symbol of the profession, that surgeons were just being
macho while disregarding what was thought to be a patient safety
issue,” said Gibbons.

“Surgeons responded that this was a power grab by the
AORN, that there are performance and comfort issues that
shouldn’t be disregarded, and that there was no good evidence
supporting the ban on the cap,” he continued. “Our
study found that there is no basis for banning the cap.”

Gibbons noted the ban was disruptive at his hospital and others
around the country and that Buffalo General already had a surgical
infection rate well below the national average.

He explained the availability of the cap is particularly
important to surgeons who wear tools, such as surgical telescopes
and headlights, mounted on their heads for hours during surgery.
Many surgeons maintain such tools are more likely to stay in place
with the skullcap versus the bouffant.

Evidence-based medicine

The debate, while important to those in the surgical field, has
a wider impact as well, he explained: “Within medicine as a
whole, we are really trying to become more evidence-based. There
are certain things proven beyond a doubt and those should be the
standards. There are other things that are not exactly
evidence-based but which the vast majority of experts agree on. And
then there is opinion. The problem was that the banning of
skullcaps was enforced at the level of a standard and it
shouldn’t have been. The rationale, not the evidence,
suggested that banning the cap would reduce infections; the
evidence is it did not.”

Gibbons and his UB colleagues authored an article, titled
“The surgical cap: Symbol, science, argument, and
evidence,” published this week in The Bulletin of The
American College of Surgeons. It reviews the debate, cites the lack
of evidence and the need to be evidence-based whenever possible; it
also cites the deleterious effect the ban and debate have had on
surgical teams and teamwork, and the need to do better.

According to Gibbons, advocates for the ban on skullcaps kept
insisting there was no harm in enforcing this ban, and maintained
it may result in fewer surgical site infections. “Our
response is, there is harm in a top-down mandate that is not
evidence- based, that disregarded surgeons’ concerns and,
most importantly, did not reduce surgical site infections,”
he said.

The Bulletin article calls for both organizations to coordinate
and cooperate on a new system that takes into account all aspects
of the debate for all the professionals involved.

Co-authors on the article are Ken Snyder, MD, assistant
professor of neurosurgery at UB and director of physician quality
for Kaleida Health; Steven Schwaitzberg, MD, chair of the
Department of Surgery and president of UBMD Surgery and Elad Levy
MD, chair of the Department of Neurosurgery, president of UBNS,
co-director of Kaleida Health Stroke Center and Cerebrovascular
Surgery, and medical director of neuroendovascular services at
Gates Vascular Institute.